Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Sunday, April 29, 2007
    Kings Cross: the Real Platform 9 3/4

    Yes, Harry Potter fans, there is one!

    Nice that British Railways decided to add this. The Wikipedia article about Kings Cross station gives more details. Me, I'd be looking for Sherlock Holmes and Dr. Watson if I were there; they often left from Kings Cross when investigating cases.


    Guatemala - IV

    Wednesday April 18

    "Humpday" is over. One more full day in the clinic and then a half day on Friday. We pack Friday afternoon and leave Saturday am. Today is classic internal medicine all the way with tons of back pain, gastritis, headache, and cough. Several of my patients also have GYN problems, so S. (the GYN nurse) and I swap patients a lot.

    One woman comes in with a list of minor complaints and then breaks down crying in the middle of the exam. Her son was murdered a few years ago and she's had other troubles at home; she is clearly depressed. I send her for spiritual counseling (HELPS offers this to patients). There just isn't much else we can do for her; we have no antidepressants available here and even if we did, how do I explain that they take four to six weeks to work, and where is she to go for follow-up and to get ongoing treatment? A lot of patients here also complain of being "nervous." We have no anti-anxiety meds and I wouldn't feel comfortable handing them out even if we had a supply. On the up side, I catch a case of previously undiagnosed diabetes in a woman with a blood sugar of 489. We give her a glucometer, educate her on diet and start her on medication. Also I see a man with a bad case of sciatica. After I give him a prescription for prednisone to get his pain under control he tells my translator that the local doctor had suggested amputating his leg for this problem. Words fail me.

    I tried to inject a knee today, couldn't get into the joint and had to get one of the other internists to help. I do love the camaraderie at the clinic. We're always popping into each other's rooms to point out something interesting or to ask for help. The number of internal medicine patients has slowed down a bit so we had more time. A whole busload of kids showed up today, brought from a local school, so the pediatricians were kept busy.

    A., the intern who's working with us in clinic, called me in to see a patient with a fever and cough, also symptoms of an enlarged prostate with dribbling when he tried to urinate. She said his lung exam was normal, so I thought: urinary tract infection. His urinalysis came back normal, at which point I examined him and heard faint crackles in both lung fields. I immediately diagnosed bronchitis and told her to put him on Avelox. Later I saw another patient with her, a boy with skin problems and low back pain. I diagnosed sacroiliac back pain and tinea versicolor. As I explained the diagnosis to her and the patient I suddenly realized that I had become an Attending. Suddenly I feel like a grownup.

    Last note for tonight is the insect life of Guatemala. As I mentioned earlier, we have been plagued by June bugs; tonight they were all over the bathroom. A. and I finally figured out that the lavaliere windows over the sink had been left open, so she climbed on the sink and I jumped up on the toilet to close them. The first night we were here I screamed when I saw those things. Now, my reaction is more along these lines:

    • Look up from book, see bug

    • Squash bug with nearest blunt object

    • Go back to book.

    I must add here that there was a beautiful little girl walking around in the clinic today, maybe 18 months old. Most of the children around here seem to fight somewhat shy of us, but she walks up to me. Her mother smiles and gestures to indicate that she wants to kiss me. I lean down and she plants a big kiss on my cheek.

    Thursday April 19

    Did I mention that Ronald McDonald showed up yesterday? I don't think so, but he did. Ronald McDonald House is a big sponsor of HELPS, so they sent Ron out to entertain the kids. Solola is such an isolated area that I doubt most of them knew who he was. He did show up in the mess hall at lunch, holding one of those "invisible dog" leashes and tooting a horn. The surgeons thought it was a hoot and lined up to get their pictures taken with him. I was not so thrilled and made a quick unobtrusive exit.

    Today is slightly quieter in clinic for medicine, but not for Peds; two more busloads of kids show up, again sent from local schools. We are now out of hydrocortisone cream, Lotrimin cream, acetaminophen (!), ibuprofen (!!) but we still have some aspirin. On the subject of pain relief, I successfully inject two patients' knees today. I also see a patient with a goiter who is clearly hyperthyroid, with tremor, weight loss and palpitations. We refer her to Guatemala City for treatment with radioactive iodine to ablate the thyroid. Another standout patient is an old guy with bad arthritis of the hip; he has a flexion contracture. What he really needs is a hip replacement but there's no way that's going to happen here. I explain the problem and give him aspirin.

    At the end of the day I see a bucket of plastic vaginal speculums, normally a disposable item, soaking in bleach solution. I ask S. whether she is reusing the speculums and she nods yes. It's something we'd never do in the States, but it makes sense here given our chronic shortages of equipment. Also it means less stuff to throw away at the end of the trip.


    Wednesday, April 25, 2007
    Guatemala - III

    Tuesday April 17

    I wake with a horrible headache at two am, probably due to the altitude. I finally get up early and go outside as I am getting nauseated, but I find the path to the overlook and walk it. I've been told to check out the overlook ever since we got here, and it certainly is a fantastic view down the mountain to Lake Atitlan, with a volcano in the background (not sure which one). For a small country, Guatemala is amply supplied with volcanoes; it has three, two of which are active. It turns out that the university campus is perched at the edge of a deep gorge, which explains the cement wall topped with barbed wire I see on my walk. Of course I didn't bring my camera along, but I decide to return tomorrow to take pictures.

    Clinic is better today; we have found our footing and everything goes much more smoothly. I stop by the hospital this morning to beg some steroid and lidocaine for joint injections (another entry on next year's list: Kenalog!) Now that the surgical schedule has more or less been set we're seeing more internal medicine patients rather than preops. We see a lot of TBA (total body aches), gastritis, headache and "nervousness." I realize today that internal medicine is the same no matter where you are. These patients' complaints are exactly the same as the patients I see at home. This is familiar, and thus reassuring, ground.

    One woman I see today does not fit this pattern. She comes in complaining of a rectal lesion which is bleeding and which she's had for over a year. I look at her and realize she's lost weight (these people don't have money to buy new clothing, and hers is clearly too big for her). Her face shows evidence of weight loss as well. I ask her, via Maria as translator, if she has lost weight and she confirms it. This does not bode well. Knowing she will likely need to see the surgeons, I decide to do the full preop exam; when I check her rectal exam she has a large bleeding external mass. It's clearly malignant. I send her to the surgeons, hoping for the best, but Maria tells me later that they could do nothing for her. She would have required a colostomy and we are not set up to do that. She is sent to Luis and Jorge in the hope that they can refer her to someone in Guatemala City.

    Another patient (not seen by me, but by one of the other MD's in clinic) has a large necrotic ulcer on her leg near the ankle. It has rolled edges, which indicates a basal cell carcinoma. Later in the week we hear that the surgeons found maggots in it during the operation. This isn't quite as vile as it sounds, as the maggots did a nice job of debriding the dead tissue in the ulcer and preventing it from becoming infected. The surgeons resected the ulcer and placed a skin graft, taking healthy skin from her abdomen: "She got a tummy tuck for free."

    I learn how to inject knees and shoulders today. Most every patient with joint pain wants an injection, as it gives instant relief that lasts for months (if you're lucky). Rheumatology and Orthopedics has always been one of my weak points, but I am game to try and hope to do some more while I'm here.

    An evening's entertainment around here is to go over to the hospital and watch the surgeons in the OR. There really isn't much else to do, and we internists are invested in these patients' outcome, having seen them in clinic the same day or the day before. Internists and surgeons traditionally get along about as well as cats and dogs, but in Guatemala we are all working very closely together and the barriers between us seem to have broken down. To be perfectly honest, under these conditions with no follow-up or continuity of care the surgeons can do much more good than we can. It's humbling to have to admit this, but it's true.

    The hospital is boiling with life. Both the stairs leading up to the building and the lobby are packed with relatives waiting to hear news; in Guatemala it is understood that your relative or someone from your village will come with you, stay with you in the hospital and help care for you while you're there. I meet up with B., another partner from the Firm who is an OB-GYN; he's come on these trips for years. He takes me on a tour of the OR. There are four operating rooms, currently booked with one septoplasty, two hernias and one room being cleaned where a case has just finished. The general surgeons get two rooms, OB/GYN gets one and Plastics and ENT split one. Compared to the stringent restrictions on surgical areas in the States, it's remarkably lax. Anyone can stroll in and watch (if you're with the HELPS group) and even scrub in if you want to. One of the other internists, an older man, brought his high-school aged grandson along; he has assisted on a hernia case already and is having a blast.

    I gave my heart to internal medicine early in my training and I've never been particularly interested in surgery per se. C. and I watch for a bit and she comments: "This is like watching grass grow." I heartily agree and head off to the computer lab to try my luck with logging on. (Last night the computers were down; service here is spotty.) As I arrive, someone asks: "Did you hear about the shooting in Virginia?"

    "What shooting?"

    "Some guy shot up a college in Virginia yesterday. It's on Yahoo!, they're calling it the worst massacre on a campus in U.S. history."

    I don't think I need to go further on this, but suddenly I am very glad that we've been cut off from the news as much as we have been. Once signed in I concentrate on email and avoid the headlines as much as possible.


    Tuesday, April 24, 2007
    Guatemala - II

    Monday April 16

    I have no way of knowing how many patients I saw in clinic today… maybe 25, maybe more. I also learned today that it's important here to eat even when you don't feel like eating: I was terribly depressed at lunch and cheered up as soon as I'd had something to eat.

    Every patient I see has a headache and stomach pain. I saw a 19-year-old male covered in tiny nodules; he brought a pathology report with him as he'd had a biopsy the previous year. The diagnosis was “pseudoacanthosis nigricans” and I have no idea what that actually is. I checked with a couple of other MD's and they weren't familiar with it either. (Add to next year's list: Derm manual!) I asked him if anyone else in his family had this problem; he said no. There was nothing we could do for the kid, but I asked Luis and Jorge, our two social workers, to try to get him to a dermatologist. Another boy I saw had extensive scar tissue over his groin and thighs from a burn he'd received five years before when a firework went off in his pocket. The plastic surgeons were able to help him.

    We saw lots more hernia cases today (we were told at the end of today that the OR could do no more hernia cases this week). I saw a woman with hypertension, blood and protein in her urine; we gave her samples of ramipril and tried to refer her to a nephrologist via Luis and Jorge. All the patients smell the same, a combination of body odor and wood smoke. It can get pretty overwhelming in these small rooms. (Also on next year's list: air freshener.) Their clothing is beautiful; some women and many men wear Western clothing, but most wear the indigenous outfits of blouse and skirt, made of home woven material that is heavily embroidered or patterned. The men wear jackets and pants of this same material. Neither have buttons or conventional belts. The fabric is pleated around the waist and then wrapped tightly with a strip of woven fabric that acts as a belt. The men also wear a square of material with a plaid or alternating square pattern over their pants, which is wrapped around the waist with the upper half of the material then folded over the belt. I will try to post pictures later.

    The OR is operating very late tonight because they’re trying to get as many surgeries done as possible. It’s 7 pm and they still have three or four more cases to do.

    Team meeting in the mess hall in one hour to discuss how things are going. Speaking of food, dinner was hamburger stew (ick), broccoli and cheese casserole, fruit and brownies. Lunch was sandwiches, black bean and pumpkin soup (quite good), and fruit; breakfast was homemade coffee cake and instant oatmeal. The kitchen staff is working hard (longer hours than we do) and is doing a good job considering the limitations they have to cope with, and really the food is not bad. It all tastes good when you've been working all day. I sit with the plastic surgeons, who are on a high from the cases they’ve seen. "We’re doing the nose tomorrow," one remarks, meaning an older gentleman with a large fungating skin cancer on his left nostril. I saw him in the clinic hallway this morning.

    "Any lymph nodes?" asks the other. The first surgeon shakes his head no. This is fortunate as it means the cancer isn’t likely to have metastasized.

    "What'd the CAT scan show?" somebody else quips. This is of course a joke as there are no diagnostic radiologic tools available except for the portable ultrasound in the OB/GYN clinic.

    "It was negative, actually," he deadpans.

    "They held a cat over him," the second surgeon comments. This is probably funnier if you're sitting in a Quonset hut at 6000 feet.


    Guatemala - I

    Got back yesterday from a ten-day medical mission to Guatemala. My hospital has joined with an organization called HELPS International to run an annual trip there to provide medical care. This is the first year I've gone, and it was an amazing experience; I'm posting the highlights.

    Saturday April 14

    We arrive early at LAX so that we can coordinate the checking of the supply bags with each passenger (each of us is allowed to check only one piece of luggage; the second is the supply bag). In the departure lounge we sit around and chat. Those who have been on previous trips, especially the O.R. nurses, swap stories. Apparently some patients are kept in the hospital recovery area up to five days postoperatively. Somehow I had assumed all surgeries would be same-day, but this is not the case; the surgeons do hysterectomies, plastic surgeries, gallbladders and hernia repairs. The medical missions originally focused on surgical care, which makes sense as it's a quick way to improve people's lives, but internal medicine is a relatively recent addition. I ask C., one of my partners who's also going on the trip, what people did last year to relax after work. "We went back to the barracks and went to sleep," she replies dryly. Okay.

    One of the dentists, hereafter to be known as Larry the Crazy Dentist, has been on several trips in the past. "You'll see birth defects you've never seen before," he enthuses. "This one guy a few years ago came in. He'd been living as a recluse. So the surgeons all looked at him and they all said, 'We want to take off an ear.' So three surgeons each took off an ear, because the guy had five ears!"

    I stare at him; he does not appear to be pulling my leg. (Ten days later, I'm still not sure.) "What's in the water there that the guy had five ears?" I ask. He shrugs.

    The flight is long but enlivened by a spectacular thunderstorm between Dallas-Fort Worth and Guatemala City. At this point it is nightfall and the plane skirts the storm to the west. This means that on our side of the plane it is pitch dark with nearly continuous flashes of lightning, as if some demented homeowner had let his Christmas light display veer out of control. Looking out the other side of the plane we see the remnants of a sunset, utterly peaceful with no storm activity at all. I like my side of the plane better.

    We arrive in Guatemala City and are bused to the Marriott. We go directly to the lounge for orientation with Megan, who's been working with HELPS for years. Her crowd-control skills are excellent; with this crew they'd have to be. The standout rules of orientation are as follows:

    • "Don't open your mouth in the shower. Don't sing in the shower. Don't use the water from the tap to brush your teeth." Bottled water is made available in the mess hall and the dorms; that's all we drink. My water bottle becomes my best friend.

    • No alcohol allowed while we're in Solola; no public displays of affection; dress modestly; no "fraternization," even with one's spouse. The dorms are male-only and female-only. These rules are set partly because HELPS is a Christian organization but also to be culturally sensitive; rural Guatemala is a very socially conservative place. I see further evidence of this later in the week when the female patients all seem quite relieved to be seeing a female doctor. They hate disrobing in front of male MD's.

    • Don't flush the toilet paper anywhere in Guatemala; throw it in the trash instead. The pipes are small and can't handle it. "The toilets will clog and your MacGyvers will be very cranky." A few times during the trip I do slip up and drop the paper into the toilet; don't ask what we have to do when that happens. You really don't want to know. The "MacGyvers" are our fix-it men, and they deserve the name.

    We are all assigned one roommate for our hotel stays, hereinafter to be known as our "buddy." We are told to make sure that our buddy gets on the bus, doesn't get lost and so forth. My roommate turns out to be a fortuitous choice as this is her twelfth trip to Guatemala with HELPS and she can answer all my questions.

    Sunday April 15

    Today we are up early to get on the bus to Solola (elevation 6000 feet). We encounter one roadblock en route due to road construction, which lasts about 20 minutes. While we wait Larry the Crazy Dentist, natty in maroon scrubs and Guatemalan hat, gets out to take pictures of locals peeing by the roadside. Why, God only knows. We arrive at Solola and settle in for a busy lunchless afternoon (the kitchen team is busy setting up and fixing dinner). We change into scrubs and start seeing patients in clinic as soon as we're done setting up. It is urgent that we do so, since the surgeons want to start operating at 8 am the next day (Monday) and we have to do the preop clearances. Triage has done a good job of selecting patients who are likely to need surgery, and we work for two hours before knocking off for the day. I'm already tired, and tomorrow will be a much longer day.

    It quickly becomes apparent that there are things we need in clinic and don't have. A short list: More K-Y (lubricant for exams). Hemoccult developer (we have cards but no developer). A watch. Urine dipsticks. More gloves. More alcohol wipes. A flashlight, as the lighting in the clinic is really bad. It's a small building with cement walls and floor, one fluorescent strip in the ceiling per room and small windows at the top of the wall of each room. The largest rooms are at each end of the building; these are assigned to S., the OB-GYN nurse who does most of the pelvic exams and some ultrasounds, and to the two pediatricians respectively. The Peds guys split their room by hanging a sheet with duct tape.

    But there is no phone to deal with, no pager going off, no night call. No drug reps. No complaints (either from patients or from me). No TV; fortunately I am TiVoing "24." It turns out that we do have Internet access, as we are quartered on the campus of the University of Guatemala Valley and there is a computer lab. The accommodations are reportedly a big improvement over last year, with nicer dorms and individual rooms (three people to a room) instead of all sleeping on cots in a big cement barracks the way they had to do last year.

    Addendum: a new problem. Giant June bugs have invaded the entry hall of the dorm. The windows are going to stay closed in our room, I can tell you. A can of bug killer applied by one of the nurses seems to help.


    Friday, April 13, 2007
    Quick Apology

    ... and an even quicker goodbye.

    You're quite right, I haven't posted in awhile. I am very sorry, and this must stop. The only excuse I can give is how wild things have been lately at work. (I spent Easter weekend on call in the hospital and my Easter dinner was a box of Kraft macaroni and cheese.) I am off to Guatemala tomorrow for a ten-day medical mission. I will post descriptions - and, hopefully, pictures as well - when I return.

    I will share this vignette with you, my favorite recent work memory. I was doing a physical on a patient and she was telling me about her niece, who cannot carry a pregnancy but had managed to find a surrogate to carry hers and her husband's embryo. The pregnancy, fortunately, is going well. The patient asked me worriedly: "I know my niece is the mother, but will the baby... absorb... some traits from the woman who's carrying the baby?"

    Me: "No. That would be the 'Horton Hatches the Egg' Gene Theory."